Credentialing Specialist, Business Office

Position Summary:

This position is responsible for prioritizing and managing tasks in the Knoxville Business Office Services (KBOS), Billing Department regarding Out of State Medicaid Payer Enrollment, Hospital and Physician credentialing. With limited supervision, the Credentialing Specialist acts as a liaison among outside vendors, Physician Groups, and Vendors. The specialist may do any of the following: Process payer enrollment, facility credentialing, physician enrollment, expirables, hospital credentialing / re-credentialing applications for KBOS providers, maintains credentialing database. Enrolls new Facility and Physician Providers with Out of State Medicaid Payers: sends out and processes initial hospital applications; performs verification of payer enrollment and reappointment applications by preparing requests for information; tracks responses and follow up on requested information.

Responsibilities

• Process enrollment, Facility and Physician enrollment, hospital credentialing or re-credentialing applications, including the review of applications and other data for accuracy and completeness; preparation and distribution of correspondence such as requests for information; verification letters; verification of licensure/certifications; background checks.
• Accurately enters required hospital credentialing data into the credentialing database, and payer enrollment data at state level.
• Follows-up on Payer enrollment, tracks/verifies hospital reappointment for accuracy, demographic changes, practice changes, and coverage arrangement.
• Verifies initial and re-verifies existing credential statuses for reappointment, medical licensure, federal DEA registration, board certification, and malpractice insurance coverage, for facilities and physicians required by the Out of State Medicaid payers.
• Assure timely processing of payer credentialing applications for assigned facilities, physicians, and ensure the VP of Revenue Cycle and Billing Manager signs required data and background checks when required. Maintains provider credential files in a neat, accurate, and organized manner.
• Expirables: Tracks and updates monthly TN State License, DEA, and Board Certifications for Facility and physicians in the database.
• Handles all payer enrollment and credentialing information in a strictly confidential manner.
• Able to respond to questions regarding general information about payer enrollment, hospital, and physician credentialing.
• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
• Performs other duties as assigned.

Qualifications

Minimum Education:

Any combination of formal education and/or prior work experience sufficient to demonstrate possession of the knowledge, skill and ability needed to perform the essential tasks of the job, typically such as would be equivalent to an Associate degree.

Minimum Experience:

3 or more years of experience in Payer enrollment, hospital, or physician credentialing; knowledgeable with Joint Commission and credentialing standards; preferred; good organizational, data entry, and communication skills.

Licensure Requirement:

None.